The Disease Management Care Blog Speaks!

The ever loquacious Disease Management Care Blog has been booked as a speaker at the January 18-19 Opal Events ACOs Summit: A Transitional Model to Full Risk Care Management 2011 Roadmap for Hospitals, Physicians, and Health Plans. As testimony to the conference's credibility, it will NOT be held in Washington DC, but in Austin Texas. The DMCB's sermonizing will focus on the "enterprise risk management" approach to management in ACOs, including the hazards of assuming that integration equals quality equals surviving risk transfer.

The DMCB is really looking forward to hearing what the other participants have to say. Instead of retreading the theoretical issues, the speakers have been asked to address various stages of ACO development and provide tangibles for the audience to take home. The DMCB is especially interested in learning from many case studies.

In Every Bowl of Outcomes, There Is a Full Serving of Disease Management!

The Disease Management Care Blog really likes this ravioli commercial. It's not only clever but speaks to the bad rap that "vegetables" don't deserve. Ditto the negative connotation that the term "disease management" likewise doesn't deserve.

In fact, with a very slight adjustment of the commercial's dialog.....




Red-Aproned Health Insurer: "Hello young government health policymaker who knows nothing about the principles of insurance, would you like to try some delicious big beef managed care outcomes?"

Young Policymaker: "Sure!"

Health Insurer: "And Academic Mom, did you know that in every bowl of outcomes, there is a full serving of ......" (points to banner proudly announcing Full Serving of Disease Management)

Academic Mom: (inhales loudly) "Hush!"

Health Insurer: "...but in every serving there is a full serving of..."

Academic Mom: (shakes head)

Health Insurer: "..but there is...."

Academic Mom: (mutters - shakes head) "Don't with the....stop... talking...." Touches nose.

Health Insurer: "..but....."

Academic Mom: "Nope!"

Academic Mom wrecks display.

The only real difference is that this has happened far more than just three times.

The Latest Cavalcade of Risk Is Up!

Wenchypoo (wise and a wastebasket) hosts the latest Cavalcade of Risk with a "Mostly Insurance" Edition." There are posts that are categorized in the "insurance" basket and then there are some that are in what the DMCB thinks fit the "interesting" basket like Stuxnet and tax scams. Well worth a read and not just because this blog made the cut.

(There's even a link to a blog post on how to manage your own health insurance. The DMCB finds it wise but would add practice barrier birth control and wear seatbelts.)

Medicare and Innovation? How About Get Out Of The Way?

The Disease Management Care Blog hasn't been much of a fan of the Commonwealth Fund. While they say they're working toward a high performance health system, the paranoid DMCB suspects their progressive agitprop is really all about promoting beret-wearing physicians who ride motor scooters to government-run clinics where they pleasantly pass the day using electronic health records to document preventive services.

So it was a nice surprise when it came across this very downloadable Commonwealth Fund Report by Mary Takach, Anne Gauthier, Kristin Sims-Kastelein, and Neva Kaye titled Strengthening Primary and Chronic Care: State Innovations to Transform and Link Small Practices. The report is 67 pages, but your trusty DMCB is pleased to offer up a condensed version for our mutual learning pleasure.

Here's a teaser quote from the report that contrasts with the current health reform orthodoxy:

"....because health care delivery is local, the federal government is neither designed nor equipped to devise and administer the specific actions states and private sector partners are undertaking."

The authors conducted "semi-formal interviews" with a convenience sample of health care leaders from States with a reputation for successful reform efforts in the areas of primary and chronic care. The key words were "initiatives," "consortia," "networks," "linkages," "programs," "task forces," "collaboratives," "frameworks," "pilots," and "communities." The States were Colorado, Michigan, North Carolina, Oklahoma, Pennsylvania and Vermont.

What worked? An ongoing, multi-year and flexible commitment to:

Payment incentives to reward outcomes. Examples included shared savings in Pennsylvania, medical home payments in Michigan and fee for service combined with tiered and risk-adjusted monthly payments that were aided by transitional payments in Oklahoma.

Infrastructure support such as sponsoring expert assistance, convening meetings and supporting shared services in the areas of teaming, learning, information exchanges, registries, e-prescribing, EHRs, hosted web portals, funding, loans and getting insurers to streamline their interactions with providers. Examples included the funding of community-based medical home "navigators" in Colorado.

Leadership leading to multipayer agreements. Examples include activist governors in Vermont and Pennsylvania as well as aggressive state agencies in Michigan and Oklahoma. One interesting tactic involved the State "brokering expenses" by collecting office practice tax returns and practice expense reports to calculate the fraction each insurer had to pay for any shared services. States not only have a powerful bully pulpit, but can leverage CHIP, Medicaid and managed care contracting to explicitly support medical homes. It also occurred to the DMCB that Governors and state agencies can shield the insures from being accused of anti-competitive behavior.

Information feedback and monitoring such as public reports aimed at test duplication, after hours access and preventive services versus benchmarks.

Certification and recognition that combined national programs (such as the NCQA) with local State-run audits (examples included Oklahoma and Pennsylvania).

The details underlying each of these five ingredients turned out to be very local and reflected different communities that were quite diverse. In contrast, the federal government's size, distance, statutory limitations and an emphasis on large practices make it practically impossible for it to perform well in settings dominated by smaller physician-owned clinics.

That doesn't mean that there aren't things that the Feds can do to help:

1) Medicare needs to pay its fair share and stop cost shifting here too.

2) The meaningful use criteria in HITECH are good. Don't mess this up.

3) Reconsider the use of demonstrations. They're too slow and often don't result in any policy changes.

4) Payment reform and grants are necessary but insufficient when it comes to getting the attention of primary care physicians.

While the DMCB has always been cautious with qualitative research like this, it finds the report credible. While the authors didn't ask about disease management, the important message is that there are States that are already light years ahead of the Federal government when it comes to reviving primary care, promoting medical homes, combining the key words above with population health management and meaningfully reforming how health insurance functions. While Medicare has committed itself to "innovation," the message here is that CMS may do better as a learning organization that catalyzes and supports the good work that is already underway.

Image from Wikipedia

The Federal Trade Commission and Accountable Care Organizations: Networks, Pricing and Cost Controls

At first glance, it's a good idea that should be able to stand on its own two feet. Promote the "accountable" coordination and integration of providers that link both quality and savings. Reduced numbers of hospitalizations, avoided visits to pricey specialists and less emergency room crowding will free up hundreds of millions of dollars. After the Feds and other insurers take their cut, those savings can be shared with the providers in upside risk arrangements named "Accountable Care Organizations" or ACOs. Set it up, stand back and let the good times roll, right?

This New England Journal Perspective points out that it's not going to be that simple. It wasn't until now that the naive Disease Management Care Blog appreciated that two, not one, Federal agencies will jointly face the "delicate task" of midwifing ACOs. While it will be up to CMS to assure that ACOs meet the statutory requirements in the Accountable Care Act, another set of hands from the Federal Trade Commission (FTC) will guard against anti-competitive price-fixing bad behavior (for example) by ACO wannabe hospital-physician groups.

To accomplish this, the Perspective author and health care and antitrust lawyer Thomas Greaney recommends that the FTC:

1) clip the wings of overly inclusive arrangements that lock up key physician groups or hospitals that lead to local monopolies. The idea is to make sure that other local health care providers can provide a credible and competitive alternative

2) insist on transparent cost and quality information so that it anti-competitive arrangements (like "most favored nation" clauses) can be spotted early and

3) not be afraid to mandate insurer premium caps and, by inference, hobble the providers' ability to raise prices.

Egads! says the DMCB. The already delayed ACO "proposed rule" regulations promise to be four times as complicated thanks to the involvement of two sets of regulators. Having the FTC define local ACO networks, dive into the small print of contracting arrangements and set prices sounds suspiciously like setting power utility rates at best and old style Poliboro central planning at worst.

Is the potential of ACO's so wonderfully stupendous that the U.S. would have to resort to this level of government involvement and detail to make them work?

The Lessons from 41 Randomized Clinical Trials of Disease Management for Diabetes Mellitus

Which is a better gauge of culinary skill? Using only the finest ingredients to concoct the consummate feast? Or, being able to dress up whatever's laying around in the fridge to make everyone full and satisfied?

The latter has always been favored Disease Management Care Blog when it comes to both cooking and research. It likes taking leftover bits of data and assembling them into a coherent meal after the fact. But that doesn't mean there isn't a role for prospectively staring out with randomized controlled clinical trials (RCTs) to make a repast from the ground up. Now that's tasty!

Case in point is this feast of a study that was published online by the CMAJ. Using the Care Continuum Alliance's definition of "disease management," the authors scoured the published scientific literature for only the finest RCT ingredients and found 41 articles. When the data were baked in a "random effects model," the mean absolute difference in blood glucose control between the intervention and control groups, as determined by the A1c, was 0.51%. Patients with poorer control of their diabetes (having an A1c greater than 8%) appeared to benefit the most. Programs 1) that allowed their nurses to "start or modify treatment with or without prior approval from the physician" and 2) with patient contract at least once a month were also statistically associated with better control. If there were adverse events (like hypoglycemia), they were more likely to occur in the control groups.

The Disease Management Care Blog didn't know that there were so many RCTs how well disease management works. A mean drop in A1c of 0.51 is also both statistically and clinically significant. What is particularly savory are the operational implications of the research: glycemic control is more likely if disease management coaches 1) operate at the "top of their license," 2) contact the patient at least once a month and 3) are reserved for patients at greater risk - not every patient needs to be or should be called by the nurses and, when they do get involved, patients are NOT put at risk.

Here's the reference for your quoting pleasure:

Pimouguet C, Le Goff M, Thiébaut R, Dartigues JF, Helmer C: Effectiveness of disease-management programs for improving diabetes care: a meta-analysis. CMAJ 2010. DOI:10.1503/cmaj.091786

Image from Wikipedia

Keep Searching Says the Fat Lady

It was the Big Bang that started it all. Since then, its background microwave radiation lingers in a massive externality of space "without walls" propelled forward in time. Humans individually inhabit this reality. We are born, we live and then we die, navigating along by seeing, hearing, smelling, tasting and feeling. Sometimes we pause and wonder what else could be beyond border zone of consciousness. Is that all there is to it?

The Fat Lady feels our pain. Our conceit is even worse she says, reminding us that our inhabited reality is not as cleanly rational as we think. At a sub-atomic level, our world seems to be made up of probability energy that collapses only when we "look" at it. In the here and now, most of the gravity we experience is unaccounted for by the known mass of galaxies and the search is on for stubbornly undetectable "dark matter." Jump up to the level of stars and light-years and it turns out that space and time are astonishingly "relative." The mathematics that describes it all ultimately doesn't really need time or distance. Rather, they're imperfect tools used by the human brain that impose order on the universe.

Keep searching, says the Fat Lady. Wise Men Melchior, Caspar and Balthazar are good role models this holiday season. Mathematicians with eyes to the sky, their earthbound gifts remind us to be mindful of the limits of our central nervous systems. The scent of frankincense is at the edge of what is seen and known, solid gold contrasts with an ephemeral world construct while myrrh makes us wonder what the "future" is really all about.

Salaried Employed Physicians Can Take the Lead on Health Reform?

The Disease Management Care Blog would like to introduce you to two alternate realities.

In the first reality, physicians own the bricks and the equipment that make up their clinics. They hire and fire their office staff members. They don't mind fee-for-service payment systems, because the harder they work, the greater the reward. "Pay-for-performance" generally results in greater practice income because they're already doing a good job unless it's Medicare. They like their patients and their patients like them. They like being in control of their own destiny.

They're anxious about health reform. They're paying attention.

In a JAMA commentary about an alternate reality written by the former New England Journal Editor-in-Chief Arnold Relman, physicians refer to themselves as "providers." They've been told about the strategies underlying their employer's capital allocations thanks to emails and evening staff meetings. Their input on human resource issues is generally not expected or necessary. They're paid a market-based salary and are expected to generate market-based patent care revenue. The details of pay-for-performance have been negotiated for them by their administrators with the insurer's administrators, unless it's Medicare. Patients populate their appointment slots. They don't mind not being in control of their destiny, just so long as they can get home by 5:30.

They're clueless about health reform. They're not paying attention.

In its travels, the DMCB has found that docs who are in physician-owned settings, thanks to their sweat equity, are far more likely to be engaged in health reform. That passion is one reason why the American Medical Association remains such a potent political force. The assumptions by Dr. Relman that salaried/employed doctors will make hospitals virtuous, attain consumer loyalty, exude professionalism, control costs, increase quality, manage global contracting and bypass partisan gridlock is silly for a single reason: with some notable exceptions, docs who go into salaried positions are, on average, less interested in the issues driving health reform and the business of medicine. Not having to worry about it is why they've agreed to be salaried and employed in the first place.

That's the real reality.

Follow-Up Thoughts on the Innovations Conference

In a prior post, the Disease Management Care Blog examined the emergence of "trade association" behavior among the presenters at the Health Affairs "Innovations" conclave. Yet, the DMCB does not weep. Between the doctrinal belief in large provider systems and the allure of $10 billion in government largess, who can be blamed for a fall from academic grace?

The DMCB can only hope that this new business-oriented posture may portend some flexibility in health system redesign. Which is why it's important to note that the disease management vendors know a thing or two about simultaneously delivering programs and conducting outcomes studies. They've developed "real world" approaches to study design, understand how to partner in large regional interventions and, what's more, know the good, the bad and the ugly of dealing with Washington DC. Who cares what color the cat is so long as it catches mice?

The bad news about the Health Affairs confab (and maybe many of the other Center for Medicare and Medicaid Innnovation "listening sessions") was the apparent lack of any mention of, invites to or presentations by any members of the mice catching disease management industry. Yet, the DMCB remains optimistic that the CMMI folks will welcome multi-dimensional proposals that include state-of-the-art patient/consumer outreach, engagement and coaching. That's why it may pay DMCB readers to (warning, it's a big file) download the PowerPoint presentations and ponder just how such a collaborative approach would work while they think about partners.

In the meantime, some other "Innovations" confab DMCB take-aways:

For many innovators, a low "N" and wide confidence intervals involving non-normally distributed data with big outliers may mean that detecting a "return on investment" will be statistically undetectable - not only at the individual work unit levels, but also at higher organizational levels. That's going to call for some "take-my-word-for-it" when these care management programs are evaluated.

One seemingly welcome innovation strategy is redirecting physician ordering to lower cost alternatives. In other words, if the name of the game is finding cheaper care options in absence of a managed care insurers doing that dirty work, that means the innovators have figured out a way of saying "no," "denied," and "not covered."

New term: "value streams," defined as clinical guidelines/care paths that are stripped of any recommendations that don't add consumer value.

One not-for-profit managed care organization executive's description of a key attribute they leveraged to get buy-in from their network physicians:

"We're the health plan they hate the least."

Ouch!

Last but not least, the DMCB was struck by unpolished yet endearing style of many of the presentations, which stands in contrast to the slick, jargon-filled and graphics-rich PowerPoints that is typical of its colleagues in the investor-owned care management industry. When dealing with this kind of audience, less may be more.

Why Appeals on the Constitutionality of the Affordable Care Act Will Not Be Fast-Tracked to the Supreme Court

The Disease Management Care Blog agrees with the spouse on one key observation about human and organizational behavior: if moms were put in charge, a lot of societal problems would be fixed - and pronto. For starters, war involving their children would end. Our nation's schools would work. 535 legislators would be looking for new employment. Taylor Swift's media ubiquity would cease.

If only.

The DMCB suspects the moms would also favor dismantling all of the lower court legal motions and appeals surrounding the constitutionality of the Affordable Care Act's individual mandate. It's going to end up at the Supreme Court anyway, so it'd be smart to just fast track it, right?

Alas, the moms aren't in charge. After researching the toxic legal issues and partisan undercurrents, the DMCB developed this handy decision tree posted above that amply demonstrates how our Republic can look forward to years of additional legal wrangling before we'll know for sure.

Email the DMCB if you want a pdf!

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The Disease Management Care Blog Welcomes A New Health Care Trade Association

According to Wikipedia, a "trade association" is a collaborative organization made up of businesses that operate in a similar area of commerce that pool resources aimed at a) public relations (education, advertising and lobbying aimed at influencing public policy) and b) standardization (uniform engineering or technical specifications, criteria, methods, processes, or practices). If form follows function, the December 16 "Innovations Across the Nation in Health Care Delivery" conference was about as trade association as you can get.

The purpose of the day long confab hosted by the folks at Health Affairs was to showcase healthcare organizations "that have innovated at the patient care level, created more highly coordinated patient care systems and improved population health." The showcasing was prominently directed at the leader and staff of the newly established Center for Medicare and Medicaid Innovation (CMMI) who treated the conclave as another one of their many listening sessions.

The Disease Management Care Blog listened in too. Once it got past the enthusiasm, PowerPoints and data, it concluded that much (not all) of the day consisted of reports of strained credibility, generalizability and scalability. The DMCB counted nine presentations relying on unsophisticated "pre-post" methodologies to support their triple aim claims, while four others contrasted their cost savings vs. projected costs of unknown pedigree. Most of the practice settings had unique cultures, economics and leadership styles that would be challenging to export elsewhere. Many also involved a local commitment of financial or organizational resources that seemed out of reach of most provider settings, even with CMMI's $10 billion.

It wasn't until the DMCB made full weekend use of spiritually-based libations to commune with the health service research and policymaking gods that it divined that it was probably the last person in the room to recognize what was really going on. Hidden under the patina of evidence-driven policymaking was a five-fold vision: 1) large not-for-profit provider groups using 2) primary care medical homes in 3) regional care systems driven by 4) an academic government alliance using 5) insurance levers to ultimately control health care. Check out at the videos and the listening will reveal classic "trade associating": a) education really aimed at convincing an already favorably predisposed CMMI coupled with b) an emerging evaluation standard that doesn't include rigorous research methodologies. All that's lacking is name, set of bylaws, a red ribbon ceremony and directors. Perhaps this will make do in the meantime?

While DMCB has been skeptical about CMS' ability to actually "innovate," it likes the "systemizing" of medical practice as well as the reorganization of primary care. The DMCB also knows trade associations are important and that their support by medical journals or government is not unusual. So, it would like to be among the first to welcome the colleagues named in this Agenda to getting the recognition they deserve. May you and yours be blessed with regulatory favoritism and being mentioned in legislation. May the organizations that want to be like you get those 6 or 7 figure grants and thousands of frequent flyer miles earned to and from Dulles-IAD.

In a future post, the DMCB will examine the implications of this in greater detail. It will also cull out the few presentations that had some useful data and insightful lessons for it's colleagues in the population health management community.

Innovations Across the Nation in Health Care Delivery Conference (with video links)

The tireless Disease Management Care Blog attended the Health Affairs sponsored Innovations in Health Care Delivery Conference in a snowy Washington DC today. It not only showcased the newly established Center for Medicare and Medicaid Innovation (CMMI), but offered up a series of presentations by health leaders from across the country on their local efforts at achieving the "Triple Aim" of better health, better care and lower costs. Not only did the DMCB learn a lot, but so did staff from CMMI who sat through the conference. If you've got the time, you can view a replay here.

As readers may recall, the CMMI was established by the Affordable Care Act (page 271). Its purpose is to:

"...test innovative payment and service delivery models to reduce program expenditures under the applicable titles while preserving or enhancing the quality of care furnished to individuals under such titles. In selecting such models, the Secretary shall give preference to models that also improve the coordination, quality, and efficiency of health care services."

"Applicable titles" means Medicare and Medicaid. Potential models for testing named in the ACA include patient centered medical home, direct provider risk-based contracting, geriatric care, use of information technology to reduce hospitalizations for persons at risk, incentives that reduce unnecessary imaging studies, medication therapy management services, patient decision support tools and others.

The Acting Director, Rick Gilfillan MD was the keynote speaker. Among the interesting points that caught the DMCB's attention:

CMS wants to be a constructive force and trustworthy value-added partner that is no longer just a claims payer.

Their three key words are "identify" innovation, then "validate" it and then "disseminate" it.

$10 billion in research grant funding over the next 10 years will be available to test the innovations. If any are successful, there is broad authority to disseminate them throughout Medicare or Medicaid. If you're going to apply for some of that money, proposals that "push" the grant toward the patient are more likely to be funded.

The Innovation Center staff have been touring the country in a series of listening sessions so that they can gather ideas on how to move forward. They want "ideas" and "suggestions." They've even started a web site so that you can keep up to date.

The DMCB will follow-up on some additional insights about the Conference and the speakers. The good news is that the Innovations Center seems genuinely interested in doing the right thing and the Conference was a good demonstration of that. Good intentions aside, however, it remains to be seen how well they will execute. More on that also.

Is This All They Got?

Writing in the September 15 Washington Post about the legal challenges to the Affordable Care Act (ACA), Attorney General Holder and HHS Secretary Sebelius once again turned to the Administration's now familiar health reform rhetoric.

By now, observers have come to recognise the White House's standard and adaptable boilerplate: open with a heart breaking anecdote about a victim unable to afford treatment for their curable condition. Follow with some framed statistics about the uninsured and runaway health care costs. Get in the usual dig at evil health insurers run amok. Lump opponents to the Administration in with the crackpots that want to dismantle anti-Social Security and roll back civil rights. Close with the reasonableness of Team Obama and a call to bipartisan collaboration.

Good boilerplate can be adapted to any argument including the latest threat to the ACA. Opponents to the individual mandate argue that the U.S. Constitution's Commerce Clause does not grant Congress the power to compel Americans to purchase health insurance in a private market. The retort in the Washington Post? Use the opening "victim" anecdote to portray what could happen if the individual mandate is rolled back. State that the uninsured and runaway cost statistics are the result of not having an individual mandate in place. Portray the individual mandate as a way of bringing insurers under control. Lump the mandate's attackers with other extremists. Close with the observation that the mandate's opponents would make better use of their time by working with the White House.

On and on.

The Disease Management Care Blog thinks the article interesting for what it didn't do:

1. It didn't reach into the heartland and is going unread by persons outside that beltway.

2. It didn't offer up an easily grasped and Constitutionally sound counter argument, other than electing to go without insurance is a form of commerce that eventually harms everyone. Rather, it spent far more verbiage portraying the mandate as the fair thing to do. They have a point, but since when were U.S. laws about fairness?

3. It didn't attack the health insurers until the seventh paragraph and even then it was rather mild. This may be bad news for the Administration, which rode voter anger against the industry to garner political support. That won't work anymore and bodes ill in the continuing Administration battle for support outside their base.

4. Finally, it failed to adequately explain how making everyone buy insurance will lower the price of insurance and simultaneously control health care costs. While the Disease Management Care Blog believes the concept of risk pooling is within the reach of most voters, they'll then have no problem also discerning that spreading unrestrained health care costs over more people will do little to ease exploding debt levels.

The DMCB hopes this is the usual public relations posturing and that some real work, negotiating, learning and dialogue is going on behind the scenes. If this is all the Administration has, health reform may be in real trouble.

The Latest Cavalcade of Risk Is Up!

So, which is it? Do you LIKE risk, or are you RISK AVERSE? You can try both out by heading on over to the latest Cav of Risk edition at Healthcare Economist Blog, hosted by the able Jason Shafrin. Take the Disease Management Care Blog's word for it - the only real risk from not checking it out is that you won't get to read the latest insights on the business of measuring, monetizing, managing and minimizing risk.

The Democrats Had Better Hope the Supreme Court Overturns the Individual Mandate Before the Middle Class Understands How Bad It Is For Them

This post first appeared as a column at Kaiser Health NewsIs The Individual Mandate Really A Lynchpin In The New Health Law?If the Supreme Court does rule the individual mandate unconstitutional will it really bring down the whole law?I don't see it.First, the individual mandate isn't even close to what it has been made to be -- a provision that would protect the integrity of the health insurance

A Lifetime of Exercise Won't Prevent Weight Gain

Does sticking to a regular exercise program year after year, decade after decade, keep you from gaining weight? According to a study just published in JAMA, the bad news answer is no. The only good news is that regular exercise is associated with less weight gain.

Sound disappointing? To millions of Americans that think they can regularly make up for yesterday's second donut with today's treadmill session, it should be. And to the processed food industry, it's an inconvenient truth.

The Coronary Artery Risk Development in Young Adults (CARDIA) multi-center study started in 1985. It enrolled 5115 young adult volunteers ranging in age from 18 to 30. Participants returned at 2, 5, 7, 10, 15 and 20 years. At each review, subjects were asked about their overall activity and exercise levels (for example, jogging, cycling, swimming, dancing or home maintenance). Those data were plugged into a simple scoring table and points were awarded that, depending on the individual activity, ranged from 108 to 288. They were then added up to yield a total score. To put things into perspective, the DMCB took the time to access the JAMA web site to find out more about the scoring. Doing home maintenance plus regularly playing golf led to 254 points. If jogging was included, the score jumped to 532 points. The authors estimated that meeting the U.S. government's activity guidelines would result in about 300 points.

To correlate the CARDIA score with body mass index, the authors grouped the study population by gender into "high," "medium" and "less" tertiles. To be assigned a tertile, participants had to score into one of the three tertiles for 2/3 of their visits over the 20 years of the study.

Men at the higher levels of exercise consistently scored greater than 608, moderate was 340 to 607 and less was below 340. Higher exercising women were greater than 398, moderate was 192-397 and less was below 192. Persons who failed to keep the "two thirds rule" were lumped into an "inconsistent" category.

At the 20 year mark, there were 3554 individuals with usable data. After controlling for age, race, educational level, tobacco use, alcohol use, food intake and starting BMI, increasing exercise levels were associated with the a lower rate of weight gain. For men, higher or moderate exercise was associated with a per year BMI increase of .14 to .15, while lesser exercise led to annual BMI increases of .20. For women, the BMI at higher tertile levels of exercise increased at a rate of .17 per year versus .25 for moderate and .30 for lesser. Everyone started out at a BMI of about 24 and over the years it increased to the 28-30 range. You can get an idea of what different BMIs look like here.

What can the DMCB conclude?

While it's a bummer, the study only confirms what has been known for years: exercise by itself does not prevent weight gain and cannot be used to decrease weight. All things being equal however, (and this study controlled for dietary intake) exercise by itself can blunt weight gain. Over twenty years, that can make the difference between being "overweight" (BMI less than 30) and being "obese" (BMI equal to or greater than 30). That's good from a public health perspective, but for us individuals, it's not going help us look good at the beach.

While it would appear that men seemed to need to exercise at a higher level compared to women to gain the benefit, the small print in the study showed no difference in the degree of weight gain between higher and moderate lifetime exercise levels. The authors noted that persons meeting the government's activity guidelines also gained less weight compared to the lowest group but the DMCB wonders if being in the 340-400 range (supplementing, say golf and housework with something else, like jogging, swimming or cycling) for both genders is where most of the benefit lies. For men, exceeding that level didn't confer any additional protection.

Disease Management Can Reduce the Variation Between El Paso and McAllen Texas

It took a while, but the Disease Management Care Blog finally caught up with this follow-up study on the contrast in health care costs between the Texas towns of McAllen and El Paso. As readers may recall, the June 2009 New Yorker exposé on McAllen's "culture of money" allegedly demonstrated all that was wrong with fee-for-service medicine. It also provided the White House with the intellectual "must reading" underpinnings for passage of Affordable Care Act.

Fast forward to this Health Affairs study. The study objective was simple: if Medicare's costs for McAllen vs. El Paso were out of control, the same should be true for other health insurance plans. That's what authors Luisa Franzini, Osam Mikhail and Jonathan Skinner anticipated when they obtained Blue Cross Blue Shield (BCBS) of Texas preferred provider organization (PPO) and point of service (POS) plan 2008 claims data for over 65,000 enrollees in each city and contrasted the results with Medicare data.

While they confirmed that McAllen's Medicare overall costs were 86% higher compared to El Paso, the BCBS data surprisingly showed that its McAllen's claims expense was 7% lower compared to El Paso's. For the BCBS enrollees that were between ages 50 and 64, the claims trended toward the Medicare pattern. For this group, overall spending was 89% higher in McAllen. This was mostly accounted for by higher levels of inpatient spending that was 117% higher versus El Paso; it was offset by lower use of outpatient services.

While the authors recognized that there were important contrasts in how Medicare and BCBS function, that health care costs can be highly variable and that there may be other demographic or socioeconomic dynamics at play, the authors also pointed to the Texas BCBS' use of population health management along with basic utilization management as another factor that allowed it to avoid Medicare's fate:

"....members with high-severity and high-expense conditions are contacted by a Blue Care adviser, who encourages members to participate in management programs. Chronic conditions and complex cases are managed through a variety of condition-specific management programs based on evidence-based interventions"

You can read more about these programs here and here. While the Medicare Health Support pilot suggested that disease management wouldn't work for fee-for-service Medicare, the success of this particular BCBS plan in a hotbed of over-utilization suggests this may be an approach that has yet to be adequately tested among Medicare beneficiaries.

In lieu of PHM, the New Yorker-reading Feds appear to be banking on the patient centered medical home and accountable care organizations as the way out from the dysfunctions of an entitlement program hooked on fee-for-service. Can either of these match the Blues' blocking and tackling with their population health and care management programs?

Check back with the DMCB to find out. In the meantime, if readers learn anything, please share.

Hospital vs. Physician Control of Accountable Care Organizations: Here's One Way To Tell Who Is In Charge

As the Disease Management Care Blog types this, countless health care administrators, consultants, chairs, deans, managers, C suite denizens and actuaries are logging countless hours getting ready for the Accountable Care Organization (ACO) gold rush. Think they're going to worry about "coordination?" Write countless memos extolling "quality performance goals?" Create business plans that are centered on "controlling costs and increasing quality?" Think again, says the DMCB. What they're really going to focus on are the power and revenue-sharing arrangements between the physicians and hospitals.

The DMCB has a small yet compelling anecdote to put this into perspective. In its earliest years as a physician "revenue center," it notified patients of their test results by picking up a handset in its office and dictating a quick letter. It took less than a minute. The letter got typed, reviewed, signed, folded, enveloped and sealed with little additional DMCB attention.

As the years progressed and its role shifted toward being a provider "cost center," the DMCB gradually assumed more of the mundane tasks of routine patient communication. Its transition to maximum operational efficiency reached its zenith with the arrival of an electronic health record (EHR) with pre-formatted letter templates. Thanks to the wonders of highlighting and clicking, the necessary text could be assembled into a letter, which was then printed at the DMCB's shared work station.

The DMCB was not impressed. While costs had certainly dropped somewhere in the organization, this unholy alliance between health information technology and the administration had ironically led the DMCB to spending more time dealing with patient letters.

You don't need to take the DMCB word for it. Check out this oft-quoted article from Health Affairs that shows how the $44,000 up-front cost of an EHR installation was offset not only by upcoding but by fewer non-physician personnel and transcription savings (look for Exhibit 2). Given the relentless pace of health care cost inflation and the voracious appetite for capital, the DMCB thinks it's highly unlikely that any of the savings made it back to the physicians or their patients in the form of higher remuneration or lower prices.

Years from now, when DMCB goes walking through the ACOs' hallways trying to figure out how things are working, it will be closely examining the physician workstations. If it sees cheap printers with stacks of outbox letters, it will know who won the physician-hospital ACO tussle.

Image from Wikipedia

The Latest Health Wonk Review Is Up!

Brad Wright of the excellent brainy blog "Wright On Health" has posted the latest holiday themed Health Wonk Review. Presents abound in this well written summary of the best policy blogging out there. Enjoy!

Vitamins and the Search for Panaceas: The Institute of Medicine and Vitamin D

In the decades old movie “A Clockwork Orange,” a soulless sociopathic monster becomes the pseudo-beneficiary of medical-psychological re-engineering. Among the many modern treatments prescribed by the white coated clinician-experts are injections high doses of “veetamins,” (the British pronunciation for vitamins), which the main character (played by a youthful Malcolm McDowell) meekly accepts. The intervention ultimately fails and the viewer is left to ponder modern society's fixation on finding panaceas that can cure all that ails us.

During its career, the white coated Disease Management Care Blog has pondered its patients' passion for “veetamins.” Years of experience led it to eventually conclude that linear “if-then” thinking had blessed vitamins with a special place in our dietary mania: if a lack causes disease, then an abundance should lead to well being. Even the word “vitamin” conjures up notions of vitality. The DMCB eventually concluded that its patients were caught up in a perfect storm made up of our collective fixation on easy answers combined with a naïve delight in anything with the patina of "science." Little wonder, then, that gazillions of vitamins pills are being sold with little to show for it, other than gazillions of gallons of vitamin-rich urine.

Enter the prestigious Institute of Medicine (IOM) on the topic of Vitamin D. The IOM sponsors expert consensus panels, workshops, committees, forums and round tables that opine on a number of medical issues while striving to be science-based and non biased. According to their recently released Vitamin D report, there really isn’t much good evidence to support bulking up on high doses of oral Vitamin D. Since average blood levels of Vitamin D in the U.S. and Canada are adequate to meet metabolic needs, it appears persons are already getting Vitamin D they need from normal and fortified foods. Finally, the evidence favoring Vitamin D as a health supplement is mostly based on observational studies that are prone to bias. As a result, they're not willing to agree that Vitamin D can reduce the risk of diseases like cancer.

Which isn't surprising. Check out this very informative (Hat Tip to the Wall Street Journal Health Blog) American Journal of Epidemiology editorial that describes the high expectations and the bitter disappointment over notions that supplemental doses of Vitamins A, B, C and E could prevent cancer, lessen heart attack rates and prolong life. Based on the sorry track record of vitamin supplementation, the DMCB thinks the IOM deserves credit for its caution.

Of course, other scientists as well as interested lay persons - who have access to the same data as the IOM - have looked at all the studies on this veetamin and have the temerity to not take the IOM’s word on it (examples here, here and here). It is their right to interpret shaky science of panaceas for themselves, says the DMCB, though it points out that their zeal for vitamin supplementation shares a Clockwork Orange pedigree.

The pic of vitamin D's chemical structure is from Wikipedia

Back to the Future—Biggest Health Plans Reported to be Building Their Own Political Coalition

I had a real sense of déjà vu this morning reading Bara Vaida’s story in Kaiser Health News:Five of the nation's largest health insurance companies are taking a key step toward building their own inside-the-Beltway coalition to influence implementation of the new health law and congressional efforts to change it. The companies – Aetna, Cigna, Humana, UnitedHealthcare and Wellpoint – are shopping

Dreaming About A Killer Ap That Measures & Credits Social Media-Based Panel Size and Shared Decision Making

The Disease Management Care Blog announces its retirement from bloggery. It has decided to commit its considerable accumulated blogging cash flow and the DMCB spouse’s retirement fund to launch a novel, venture capital-backed and "killer" web application.

Well, not really, but read on. The DMCB can fantasize, right?

It’s called HealthyFacebookery. This novel and robust smart-phone, cloud-based and social-media technology package takes advantage of the evolution of provider-patient relationships away from "production line" face-to-face encounters. As patients and doctors will tell you, office visits have been hollowed out by the need to create medical record entries and health insurance claims. This application will leverage the growing preference of consumers for on-line relationships. As regular readers of the DMCB know, this new social media is now defining the virtual dimensions of physician care.

HealthyFacebookery offers several solutions.

First of all, it can be used by savvy buyers and insurers to assess providers' true productivity and risk-adjust provider payments. By using web crawlers that catalog and weigh the number and intensity of on-line “friending" and other interactions, Healthy Facebookery will add a unique level of granularity to insurer network management. This is paying for email visits Ver. 2.0.

In addition to gauging the quantity and quality of virtual doctor-patient relationships, Healthy Facebookery will also leverage patient centeredness by assisting users' access to unbiased and vetted information about nationally recognized and recommended care interventions. It relies on the key principle of shared decision making (SDM), in which the patient, after receipt of unbiased and trusted information and decision support, is ultimately empowered to trigger care based on his or her own preferences and values. HealthyFacebookery will seek consumer friending on behalf of providers and, if approved, will offer links to any on-line resource that provides facilitated decision-making. Modules that are free of any advertising and that are game-based will be favored. HealthyFacebookery will not create any content but will be happy to accept fees or profit sharing with those who do, assuming they also link the widely read and excellently written Disease Management Care Blog on their corporate web sites.

Finally, HealthyFacebookery's patented technology will also measure how often participants used on-line shared decision making. In other words, it will assess how many participants were not only informed, but how often they considered recommended care interventions. HealthyFacebookery patented online measurement protocols will help health insurers understand and support this independent decision making of their beneficiaries. It will recognize that patient-consumer-users have the right to make "informed refusals." What's more, this application will assure that providers are credited when their patients participate in shared decision making. Insurers will be able to use these twin measures of "considered" and "decided" as a state-of-the-art metric of patient centeredness. This makes HealthyFacebookery a classic disruptive measurement technology that makes standard denominator-numerator quality assessment methodologies destined for obsolescence.

You read it here first.

Disease Management Plus Chronic Care Model Is Better Than the Chronic Care Model Alone: Two Reports

Fans of “disease management” may want to be aware of two just released reports.

The first is a hot-off-the-presses Health Affairs report "German diabetes management programs improve quality of care and curb costs" by Stepahie Stick and colleagues at the University of Cologne. It describes the outcomes associated with a German disease management program. While the lessons from Europe’s health care system may not always apply the United States, the Disease Management Care Blog thinks this particular manuscript may have an important lesson for the United States.

First, a quick description of Germany’s system. As the DMCB understands it, the German "Statutory Health Insurance" system consists of 115 not-for-profit “sickness funds” that are financed with a combination of employer contributions and government funding. It covers 90% of the German population. A “Risk Compensation Scheme” actuarially redistributes funding on a risk-adjusted basis between each of the funds. That’s important because insurance enrollees with a higher burden of illness “attract” extra funding. As described below, that extra funding was used to help bankroll disease management.

In 2002, Germany used the Chronic Care Model (CCM) to institute nationwide "primary care-based programs" for diabetes, breast cancer, asthma, COPD and coronary heart disease. They promoted guidelines, quality assurance programs, access to trained facilitators, benchmarking, reminders, physician education and peer feedback with risk adjusted measures. Physicians were expected to provide education to their patients, coordinate care and document treatment plans.

Doctors and their patients were also given access to vendor-run disease management programs. According to the Health Affairs article, while physician and patient participation DM was voluntary, patients who signed up got breaks with their office co-payments and “better service such as appointments within a certain time frame." This was partly possible because in 2007, the sickness funds received a payment amounting to $1,916 from the Risk Compensation Scheme for each patient who was enrolled in a disease management program. That figure was later adjusted using a comprehensive “morbidity oriented risk compensation” methodology.

So with that as background, the authors compared the patients who signed up for disease management to those who didn't in the BARMER Ersatzkasse” sickness fund. The period of study was for four years. On the basis of insurance claims, the authors found approximately 234,000 persons who appeared to have diabetes. The authors then further limited the population to persons who had filled three prescriptions for a diabetes medication during the 2002 baseline year. This yielded a population of 91,696 persons. Propensity matching, using age, gender, zip code, insurance status, baseline costs, hospital diagnoses and drug prescriptions was then used to find otherwise identical patients for study. This yielded 19,882 one-to-one matches.

There were big differences in outcomes between the two groups. By 2007, death rates were 2.3% for the disease management group vs. 4.7% for the matched group. There were lower rates of myocardial infarction, stroke, chronic renal insufficiency and amputations in the disease management groups. Mean cost differences (euros had to be converted to dollars) from the 2002 baseline to 2007 for the disease management group vs. the control group totaled $1443 vs. $1890, respectively, which was statistically significant. It was mostly accounted for by lower hospitalization rates. When the per patient difference of $447 was compared to the disease management program cost $238, the net savings was $209

While there are limitations from any retrospective observational study, this publication is important because it shows that disease management layered on top of the chronic care model can yield additional savings. While it is possible that disease management "bested" the Chronic Care Model, the DMCB thinks it's more likely that disease management's impressive impacts on complications and costs was made possible by the synergies of being associated with the Chronic Care Model. The DMCB speculates that the Model prompted awareness of population-based care among the physicians and helped them and their patients take advantage of the vendors' offerings.

There may be a lesson for the United States. The authors point out that Germany's Nike "just do it" adoption of disease management contrasts with the cautious “piloting” of population health in the United States. Based on what we know about the Chronic Care Model, Patient Centered Medical Home and disease management on our shores, there is little reason to doubt that a similar approach with a heavy emphasis on the primary care physician as the program manager would succeed. Hopefully the upcoming Accountable Care Organization (ACO) pilots will take note and include this in their planning.

There's an important second report that has been ably reviewed by Vince Kuraitis over at his e-CareManagement blog. If the wording includes the term "disease/care management" and Vince calls it a Home Run, then you know it's something special. This involved Massachsetts General Hospital and its physicians in an initiative that was similar to the German experience outlined above: physicians were in an "integrated" care setting (sounds like Chronic Care Model to the DMCB) and worked with case managers who provided education, support and coordination. There was a return on investment that, depending on the methodology, ranged from 2.65 to 3.35

Image from Wikipedia. That's the magnificent Cologne Cathedral in Germany, the home town of the Health Affairs authors. The DMCB climbed one of those towers not too long ago.

Weight and Mortality: Fear Not, It's Not That Bad

The Disease Management Care Blog is surrounded by death and destruction. Sea water will soon be lapping on its property line, radiation is in its airports, toxic mercury is in its compact fluorescent bulbs, killer E. coli is in its ground meat, invading Staph is on its skin and now the Grim Reaper is lurking in it's chubby abdominal paunch. At least that's the apparent message from this article published December 2 in the New England Journal. Mainstream media is spreading that alarm. Fat can shorten life. Fat is risky. Fat leads to higher mortality. Yikes!

But there's nothing like looking at the original article and underlying data to quell its panic. The authors pooled data from 19 observational population studies taken from the National Cancer Institutes's "Cohort Consortium," resulting in a database of 1.46 million adults. The median age was 58 years and the median body mass index (BMI) was slightly elevated 26.2 with a range at went from 15 to 50. The tricky part in the study was to statistically neutralize or exclude the impact of other determinants of mortality, like physical activity, past or current tobacco use, alcohol consumption, educational achievement and marital status. The authors then calculated hazard ratios for different categories of BMI. Hazard ratios can be thought of as measures of relative risk compared to a reference group.

In this study, persons with a BMI between 22.5 to 24.9 had the lowest mortality, so they were considered "one." Among non-smokers, the hazard increased as BMI increased: it was 1.03 if the BMI ranged between 25 to just over 27, 1.17 if the BMI was 27.5 to 29.9, 1.39 if it was 30-34.9, 1.98 (in other words, it almost doubled) if it was 35-39.9 and 2.92 if 40-49.9.

Sounds awful, right?

But while the hazard ratio from being fat can increase by "17%," or "39%" or "double," the DMCB asks: what does that mean, exactly? If in relative terms, if the death rate at baseline is one in a thousand and it "doubles" to two in a thousand, it that bad? On the other hand, if the death rate is one in ten and it doubles to two in ten, that sounds a lot worse. Which is it?

In the DMCB's read of the Journal article, it couldn't get a fix on this absolute hazard or risk of death. However, it took comfort in this graph using the same sort of data that appeared in a Lancet Letter to the Editor. As weight increases, yearly mortality "steeply" increases from about 5 per thousand (that's less than 0.5%) to about 8 to 9 per thousand (as in less than 1%). For smokers, the numbers are worse, but still in the range of 1-2%.

In other words, death rates can double with weight gain, but in absolute terms, the personal risk to the overfed DMCB seems to be pretty small. The "hazard ratio" increases 30 to 100%, but the absolute odds that DMCB will survive the year along with the rest of its skinny colleagues is very very good.

Better, says the DMCB, to relax. That's why, when it goes local mall for some holiday gift shopping and stops at the food court this season, it will fear not. Better, it says, to enjoy its shake, pizza and fries and celebrate.

What Would Happen If You Were To Pass a Big Health Care Bill Without Bipartisan Support?

During the recent health care debate I heard many people on both sides of the debate worry out loud about passing a heath care bill that did not enjoy broad support.I guess this question is no longer a theoretical one.December will be a big month when it comes to seeing some of the fallout accruing from the very partisan passage of the Patient Protection and Affordable Care Act.First, the White

i remember

Geneviève Bergeron

Hélène Colgan

Nathalie Croteau

Barbara Daigneault

Anne-Marie Edward

Maud Haviernick

Maryse Laganière

Maryse Leclair

Anne-Marie Lemay

Sonia Pelletier

Michèle Richard

Annie St-Arneault

Annie Turcotte

Barbara Klucznik-Widajewicz

Driving An Insurance Exchange in 2014 - A Conversation From the Future

On some weekends, the Disease Management Care Blog listens in on a certain car-themed National Public Radio call-in show that features the often entertaining and sometimes helpful advice of two wacky automotive repairmen brothers.

They’re the inspiration for this futuristic posting on another Golden Boy of health reform called “insurance exchanges”…..

Click: ….. and that’s why the answer to this week’s puzzler is that you have to cut the banana in half and then divide it into thirds! But now its time for another caller.

Caller: Hello, my name is Marcie and I’m calling from Lake Nogebow, Illinois.

Click: Hello Marcie. What’s on your mind?

Marcie: Well, I drive a 2014 Insurance Exchange and it's driving me crazy. I can’t get it out of first gear and it will only go to one place no matter how I much I turn the wheel!

Clack: Hey, that’s what my wife says about me nyuck nyuck nyuck!

Click: Marcie, I have bad news. You’re not driving a "Fix It Again Tony" or FIAT, you’re driving a DIAB or a Defund It Again Boehner! That jalopy may need to be junked!

Marcie: Oh no, my State paid millions of dollars for it!

Clack: My wife paid nothing for me, so what a good deal for her nyuck nyuck nyuck!

Click: Well Marcie, Insurance Exchanges were manufactured using parts made in Massachusetts using European engineering. That's a really bad combo.

Clack: And we know nothing good comes out of Massachusetts, just look at my brother!

Click: Unfortunately, it’s impossible to adjust the innovation to actuarial equivalence ratios anywhere in the drivetrain. There’s a shortage of new insurance design parts and drivers can’t read any of the dials to easily compare one insurance plan to another!

Marcie: So that’s why I can’t steer my Exchange to a benefit design that I want or that I can afford....

Click: That’s right Marcie. This is just like the government’s approach to electric cars: you can have any kind you want, any style you want with any features you want so long as it’s a Chevy Volt.

Marcie: Oh, my wife is going to be so mad!

Click: There was good advice back in 2010, like this from the Brookings Institution that was published in the American Journal of Managed Care. Those heavy weight authors recommended that Insurance Exchanges be specifically configured to promote a wide array of innovative benefit plan designs. In addition, they argued that Exchanges need to provide consumer-friendly information on quality, cost and patient experience information. The Disease Management Care Blog also warned its readers, but few in government seemed to think about it.

Clack: When the subsidized public option was inserted in the engine, it was all over nyuck nyuck nyuck!

Marcie: So that's why I can only go to one place in it!

Click: You're right. Since the government ultimately decided which insurers appeared on the exchange and the decision logic favored the public option, "crowd out" happened faster than an Obama tax-cut veto.

Marcie: So what should I do?

Click: Now that's a puzzler!

"Care and Cost"

Good friends David Kibbe and Brian Klepper have finally started their own blog--aimed at becoming a forum for many contributors to the health care debate.I suggest you add, "Care and Cost"––"Health Care Conversations About Hard Choices and Emerging Solutions" to your bookmarks.

Disease Management, ie Population Health Management Organizations (PHMOs): Plan B to Support the Creation of the Patient Centered Medical Home (PCMH)

As the Disease Management Care Blog has previously pointed out, there is is a lot that the disease management industry has to offer the Patient Centered Medical Home (PCMH). That's why it agrees with this webinar summary that appeared in the latest issue of Population Health Management.

In it, Darren Schulte MD of Alere points out that expectations for the PCMH are very high. Its value proposition includes reversing the decay of primary care, meeting the consumerist needs of an aging population, increasing quality and securing additional practice income. A growing body of evidence suggests that the more successful PMCHs have 1) a dedicated non-physician patient coordinator, 2) expanded in-person and virtual patient access, 3) health information technology that includes a functioning registry and point-of-care decision support and 4) increased practice income. Without these key ingredients, PCMHs have an uphill battle managing a population of patients, building a team-based culture and marshaling resources to change patient behavior.

Enter disease management vendors, although Dr. Schulte prefers to use the politically correct term "population health management organizations" (PHMOs) They have decades of experience in patient education, monitoring, self management, treatment adherence and care coordination. Despite physician skepticism and a cultural bias that favors "build" over "buy," he argues that PCMHs may find PHMOs attractive not only because they're speaking the same language, but because their services are "plug n' play" and highly adaptable across a wide variety of small to large settings. All that needs to be worked is out how PHMO support will be paid for so that the PCMH succeeds.

Enter Dr. Greg Sharp of Ideal Family Healthcare in Woodland Park, CO. He notes that health insurers have a key role to play because they're not only providing the additional monthly payments for the PCMH, but they're being called on to support health information technology solutions and provide work-flow consultation services. Since insurers are very involved anyway, he implies that it's not a great leap form them to also facilitate the sponsorship of PHMOs in the PCMH network. Once that happens, he sees few barriers standing in the way of PCMH team members virtually working with remote or in-person PHMO health coaches, accessing the PHMO's registries and relying on PHMO decision support tools.

The acronym addled DCMB likes this description of how insurer sponsored PHMOs can help PCMHs. For a fiduciary and risk-bearing health insurer, the DMCB agrees that the road to patient behavior change, prevention and savings in medical homes may run through disease management. The DMCB suspects many primary care practices won't necessarily want to create (training the non-physicians in behavior change and coaching?) or be able to afford (buying the hardware and programming expertise to create a fully functioning registry?) all the features of a fully transformed PCMH. Calling it "PHMO" instead of using the scorned term "disease management" will also increase its acceptability.

Smart health insurers will recognize that there will be primary care sites that want to go their own way in establishing PCMHs. That's fine. For those primary care sites that may not have the resources or the inclination to build a fully functioning PCMH, bringing in a "population health management organization" vendor is a good Plan B. That disease management Plan B is a rose that by any other name still smells as sweet in the science of increasing quality and optimizing costs.

The Definition of Medical Necessity and Using It When Dealing With Health Insurers

Physicians, meet Mrs. "Smith." She's undoubtedly resembles many of your own patients. Like them, she is very frail and has more than her fair share of chronic conditions. Thanks to your diligent care, she has a good chance of seeing her great granddaughter this summer and, if the both of you are lucky, she won't see the inside of a hospital for years to come.

Unfortunately, however, the times they are a changin'. Mrs. Smith's health insurance may no longer "cover" your referral for a specialist consultation, your order for a expensive radiological imaging study or your prescription for a new medication. That's because she has been caught up in a thicket of shifting benefit designs, utilization management initiatives and coverage exclusions. Dealing with her insurance company is a maze-like exercise in professional frustration that sucks the joy out of medical practice faster than salaried docs exiting an Urgent Care Clinic at the end of their shift.

When the DMCB teaches, lectures and provides conferences for young physicians and medical students, it says the fix for Mrs. Smith's dilemma is two-fold.

First of all, it says, physicians need to familiarize themselves with the basics of health insurance. Once docs understand risk transfer, underwriting, trending, contracts, reserving, surplus management and regulatory oversight, the DMCB thinks they'll be better able to advocate on behalf of their patients at both a local and national level. That will take time and effort. It's too important to leave to the experts. One good way to deal with that is for docs to regularly read the DMCB.

Secondly, docs need to learn to use the words "medical necessity." This is one of those basics described above that, if raised at the right time when dealing with an uncooperative health insurer, is more likely to get Mrs. Smith the coverage for the services.

Medical necessity is a key concept used by insurers and regulators to describe any health care intervention that is:

(a) recommended by the health care provider;
(b) treatment for a medical condition;
(c) at an appropriate level of service or supply
(d) considered to be effective in improving health outcomes, as determined by scientific evidence, accepted standards of medical practice, or, expert opinion
(e) cost-effective for this condition compared to alternative interventions
(f) not solely for the covered person’s convenience or the convenience of the covered person’s family or physician.

While there are exceptions, health insurers are obliged to cover all medically necessary services.

The DMCB recognizes that calling an insurer's 800 number, faxing copies of medical records, completing preauthorization forms and tabbing through a web site can a dreadful and demeaning experience. That's not the point. The point is that, a live employee of the insurer is going to have to eventually read or listen to what you have to say. Physicians' chances of prevailing on behalf of Mrs. Smith will be significantly increased if that employee hears or reads the words "medically necessary" somewhere in the course of your appeal. If they know that you can argue the merits on that basis, your chances on behalf of Mrs. Smith will improve.

How not to deal with an initial denial for payment coverage for a CAT scan:

"I want to rule out a tumor, so I need this imaging study stat. Please approve"

A better way to deal with that denial for a CAT scan:

"As a physician, I've determined that this patients' new symptom of pain could be consistent with a diagnosis of cancer. A CAT scan is the best first step imaging study to address this possibility based on my professional judgment and prevailing practice standards. There is no reasonable alternative imaging modality or other option to adequately address the diagnosis. I and my patient look forward to hearing from you shortly about coverage for this medically necessary service."

Grand Rounds Is Up and the Disease Management Care Blog Is Included

The Disease Management Care Blog has never ever been in "Grand Rounds," a compendium of recent blog posts that deal with medical topics. This one has links to posts about thyroidectomies, the practice of internal medicine, the medical implications of airport body scanning as well as a posts dealing with the various impacts of policy making on the practice of medicine. The DMCB is still working its way through all the great reading. It's well worth your time.